Improving the Usability of Electronic Health Records

Recommendations from the American Medical Association

Nurse holding electronic unichart entering patient record, close-up
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While the adoption of electronic health records (EHRs) has increased in ambulatory and hospital settings, health care providers are still struggling to use EHRs in an effective, efficient, and safe manner. Many EHRs are not designed or implemented in a way that fits into the workflow and thought processes of physicians. This is a problem of usability.

The American Medical Association (AMA) proposed that major EHR usability problems need to be addressed to improve the way physicians use EHRs. This article will review the eight usability issues and describe the extent to which they have affected my experiences with multiple EHRs through the years.

“Enhance Physicians’ Ability to Provide High-Quality Patient Care”

This first usability priority might be considered an overarching metric for judging the usability of an EHR. Instead of distracting or slowing down physicians, the EHR should make the physician more effective and efficient.

In reality, using an EHR often interferes with the clinical encounter or distracts the physician from paying adequate attention to the patient. It’s easy to spend half the appointment entering orders, clicking through multiple screens, and dealing with pop-up alerts -- time which would be better spent listening to and examining the patient.

“Support Team-Based Care”

Team-based care in an institution with an EHR is not possible if the EHR doesn’t support the physicians and team leaders in delegating work to other members of the team. There is no clinical rationale for requiring physicians to perform EHR-based tasks that an appropriately trained nurse or medical assistant could do.

If electronic messaging with patients is a feature of the EHR, then all members of the health care team should be able to use that feature to conduct transparent communications with the patient.

The EHR should help rather than hinder health care professionals in operating to the full extent of their licensure and privileges. A simple task like following a standing order for a flu shot should not depend on a physician entering the order.

“Promote Care Coordination”

Care coordination in this context is the ability of the health care team to follow patients across transitions of care, such as when a primary care provider refers the patient to a specialist or when a patient is discharged from the hospital. This underscores the importance of interoperability in health information exchange to allow EHRs and other clinical information systems to share patient data.

“Offer Product Modularity and Configurability”

Not every physician practice or health care organization can purchase and implement a full featured EHR. But there is a lot of territory between paper records and a comprehensive EHR. Vendors should offer a basic EHR which can be enhanced with proprietary or 3rd party add-on modules for decision support, patient portal, analytics, and other functions. The Allscripts Open API initiative is an example of how the functionality of an EHR can be expanded through modularity.

“Reduce Cognitive Workload”

Friedman’s Fundamental Theorem of Biomedical Informatics states that “A person working in partnership with an information resource is ‘better’ than that same person unassisted.” A physician working with an EHR should perform better than that same physician without the EHR. Unfortunately, the EHR sometimes taxes the physician’s cognitive capacity more than using paper records would. Instead, the EHR should help physicians by displaying the right information at the right time in the right place.

For example, the EHR should display test results alongside the window for writing a message to the patient about the test results. This may seem like an obvious usability principle, but it is not always reflected in the design of current EHRs.  

On the other end end of the spectrum, there is such a thing as too much information in the EHR display. Notes bloated with templates, cluttered problem lists, and disruptive alerts can distract physicians from the important information in the clinical record.

“Promote Data Liquidity”

AMA calls upon vendors, the Office of the National Coordinator for Health Information Technology, and other stakeholders to establish standards for clinical data exchange. Health information exchange is not sufficient for supporting clinical care. The goal is to achieve semantic interoperability, which is the ability of disparate clinical information systems to interpret, organize, and use the exchanged information. Another issue of great importance is the ability to match patient identities across health care settings.

“Facilitate Digital and Mobile Patient Engagement”

Despite the enormous potential of mobile health technologies to reshape health care, progress will be limited by the extent to which devices and software can communicate seamlessly with EHRs. Interoperability should not be restricted to connecting EHRs to one another, but should also encompass all clinical information systems, including mobile health platforms.

“Expedite User Input into Product Design and Post-Implementation Feedback”

Many EHRs were originally designed to support administrative and billing functions. But today, EHRs are expected to play a major role in improving health outcomes, health care costs, and patient experiences (Triple Aim). This will not happen unless vendors seek and incorporate input from clinicians in the design, production, implementation, and evaluation of EHRs.


American Medical Association. Improving Care: Priorities to Improve Electronic Health Record Usability.  Accessed on September 27, 2014

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